Effectively managing hidradenitis suppurativa

Hidradenitis suppurativa (HS) may be the most serious skin condition that dermatologists commonly treat. A few basic strategies can help improve management approaches and patient outcomes.

“We have multiple studies showing that hidradenitis is probably the worst disease that we commonly treat in the office,” said Christopher Sayed, MD, assistant professor of dermatology at the University of North Carolina. “You can have a dramatic impact on your patients’ quality of life when you improve your management skills and strategies.”

Medical managementTopical and oral antibiotics are the mainstay of medical management for hidradenitis, but many patients need more intensive therapy. IV antibiotics are one approach. Biologics are another.

Adalimumab was approved by the Food and Drug Administration for moderate-to-severe hidradenitis in 2015, but there is growing literature to support the use of other TNF inhibitors, as well as at least one interleukin-1A antagonist, anakinra, Dr. Sayed noted.

Laser managementLaser treatment has expanded dramatically in recent years, he continued. CO2 lasers are widely used for excisions. Nd:YAG and alexandrite lasers are useful to destroy hair follicles that have become involved in hidradenitis.

“People will argue over CO2 lasers and blades for excisions,” he said. “Either tool is good with the proper training and experience.”

Surgical managementSurgical management plays a major role in treating hidradenitis, but it is often underutilized and limited to incision and drainage procedures in dermatology offices.

“Like any surgery, unroofing takes some practice as well as recognition of where lesions begin and end,” Dr. Sayed said. “That’s where specialized tools like a fistula probe are helpful, and tailoring the procedure to the disease the patient has. Surgical management can be highly effective, but it is more than just cutting out a large patch of skin.”

“Some patients can get by with just a single management technique, maybe medical for an early stage patient or surgical alone for a patient who has a single, isolated sinus,” Dr. Sayed said. “But the majority of patients need both the medical side and the procedural side, whether it is laser or surgical, to maximize clinical impact.”